Where I Think Health Care in CA Is Going

Today Dan Weintraub did a story on how the "top three" health care reform proposals (Schwarzenegger, Perata, Nuñez) compare to one another. What's most interesting about this comparison is how little the Governor's proposal actually differs from the two Democratic leaders in the Legislature. In many ways, the Governor's plan is better, in many ways vice-versa. But what's most significant is how the only health care proposal to have passed the California legislature, SB 840, is not part of this comparison, despite the fact that Sheila Kuehl, my state senator and chairwoman of the Senate Health Committee, fully plans to re-submit it for authorization. Kuehl's plan has been marginalized by the traditional California media, along with many others. But Kuehl herself is being very vocal about the limits of the Governor's plan, in both the LA Times and on the state blog The California Progress Report. Kuehl has been magnificent in talking about this issue, and in doing so, she is providing a very valuable service for the state, in moving the conversation toward a more progressive direction.

Kuehl's great piece in the California Progress Report is unsparing.

The Governor has consistently described his proposal as “universal healthcare", promised it would cover all of California’s children, and indicated that everyone---doctors, hospitals, businesses, insurance companies and consumers---would have “shared responsibility” in paying for the plan. The press has dutifully repeated his phrases, in almost every case without a modicum of analysis. The details of the proposal reveal quite a different picture.

The central basis of the Governor’s plan is simply to mandate that every Californian must, by law, carry health insurance. There is no requirement that it be affordable and no minimum coverage. This means that the requirement can be met by a bare-bones policy covering only catastrophic events, with a $5,000 deductible and up to $7500 in out of pocket expenses for all the things that aren’t covered by the policy.

This is not universal health insurance. Think for a moment about automobile insurance. Even before Prop 103 passed, limiting the amounts by which insurance companies could raise your auto insurance premiums to those approved by the Insurance Commissioner, we all had to have auto insurance. Would you call it Universal Auto Insurance? 25% of Californians don’t comply --- so many that we all have to carry Uninsured Motorist Insurance, in effect paying more for those who are uninsured, just as the Governor has suddenly discovered we do in the area of healthcare.

His proposal would simply continue this problem in the much more complicated and important area of health insurance, with no controls on raises in premiums and no requirement for comprehensive or even adequate coverage, so every Californian could be required to pay high premiums, high deductibles, high co-pays and high out of pocket expenses, for very little coverage.

In a conference call put together by the California Courage Campaign (now available online, and it's a good discussion, go listen), George Lakoff put it best: there's no cap on insurance company profit, and no cap on what individuals would pay, and no floor on the level of basic care. "Not much of a plan," he said. But this has been lost in both state and national coverage, with reporters on all sides of the political spectrum instead repeating glowing praise about how great it is that a Republican governor is proposing universal health care. Except he's not. This isn't health care for all, it's "crappy health care for all." And I don't think it's necessary to bend over backwards and say how positive it is that a Republican governor is talking about insuring all the citizens in his state. That Republicans haven't talked about such an obvious measure, an expression of basic human dignity, up until now is an indictment. You don't give somebody a reward for staying out of jail, that's what this rush to praise seems like to me.

What's important about Kuehl's article (and you really should read the whole thing if you want to understand what's really happening) is how it turns the whole issue on its head. If Perata, Nuñez and Schwarzenegger are the only ones participating in this debate, then there's nothing more than a haggle over details, with the same basic framework of a substandard plan in place. With Kuehl as a factor (and she most certainly is, as the chair of the relevant committee), the debate shifts leftward. She's the only one calling the Governor out on his plan.

Conservatives in the Legislature have focused fiercely on what they call an employer mandate. But the Governor’s plan requires only those California businesses that employ 10 or more to provide minimal coverage to their employees or to pay 4% of their payroll into a central government fund, which would then subsidize the purchase of private insurance by their employees. Only 20% of California businesses employ more than 10 people. Of these, 80% are already providing some health insurance to their employees, at a cost of 9-11% of payroll. In a way, this is an invitation to businesses to reduce what they pay for health insurance for their employees. 4% of the payrolls of businesses with more than 10 employees would not be sufficient to provide healthcare for their employees. With a limit on what the businesses pay, but no limits on what employees pay under the mandate, even more of the premiums, co-pays and costs would devolve on employees than they do now.

She attacks the governor's plan for not providing any sort of minimums for basic coverage (in fact, he wants to eliminate regulations that require certain minimum standards in insurance coverage). She hits it for having virtually no cost-containment measures (outside of asking everyone in the state to do push-ups). She hits it for not capping the cost of coverage to consumers who must buy it, and how this "hidden tax" whereby everyone pays more for insurance because of the uninsured will turn into a real tax, as higher-risk consumers are absorbed into insurance actuarial models. She looks at it from every possible angle and tells the truth about what it really does. And finally, she makes this vow:

The Governor’s proposal is seeking a legislative author. When one is found, a bill will be introduced, either in the Senate or the Assembly and will be heard by the Health Committee in that House, the fiscal committee, go for a Floor vote and start all over in the other House. There will be heavy negotiation between the Speaker of the Assembly, the President of the Senate and the Governor as to any legislation to be adopted in this session. At the same time, my single payer bill, SB 840, will be reintroduced and follow a similar, but parallel, track.

It's important that there's a second bill in the chain. Actually, according to Majority Leader of the Assembly Karen Bass, there are about 15 plans submitted by legislators so far. Additionally, there's the Health Care for America proposal from the Agenda for Shared Prosperity think tank (the short version: Medicare for all, with significant cost containment). Plus, the SEIU is putting together a major universal health care proposal and education campaign. It's important to note that much more work needs to be done in explaining the benefits of single-payer, universal health care to all citizens. Single-payer routinely gets drubbed at the polls, by 40 and 50 points. It's key to start a broad campaign, bringing people together to understand why single-payer is so significant. The various special interests who want to preserve the status quo are very coordinated and very rich. They'll go after even the most triangulating sell-out of a plan like the Governor's. So, the argument goes, you might as well offer as people-friendly a proposal as possible, since you're going to need a massive amount of public support to carry it through. But what's most important is that you need a lot of plans in the mix. There needs to be some flag planting on the single-payer, universal insurance front so that the negotiation can be pulled in that direction. SEIU has vowed to put their proposal on the state ballot in 2008 if it's not adopted in 2007. This may even happen IF A VERSION OF THE GOVERNOR'S PROPOSAL GOES THROUGH. That's how you do it. You force the Governor to look over his shoulder.

The Governor's plan got into more trouble this week when the 4th Circuit Court of Appeals upheld a lower court decision that struck down Maryland's law requiring big employers like Wal-Mart to spend a minimum of 8% of its payroll on health benefits. A similar mechanism is in Schwarzenegger's plan, and the fact that it could be seen as an employer tax means that it could require a 2/3 vote of the legislature (so Republicans could essentially derail it). Incidentally, this is the same kind of tax which Schwarzenegger decried in Phil Angelides' proposals last year. When a Republican imposes a tax, it's not a tax, it's a fee, I guess.

The next nine months are going to be a very important time for the future of the country. California will most certainly set the debate for how health care is distributed and paid for. It's vital that the progressive voice has a place at this table, and we can support the efforts of both Sheila Kuehl and the SEIU by advocating their position and helping with their education campaigns.